Abbvie Names Magellan, EmpiRx, and CapRx in Amended Suit

Abbvie names Magellan, EmpiRx, and CapRx in amended filing targeting employer health plans use of financial assistance programs.

AbbVie is the manufacturer for the world’s most profitable drug of all time: Humira. Taking in over $200B in revenue with a >50% profit margin.

Long the thorn for employer health plans, Humira’s pre rebate cost is nearly $85k/year per patient.

Humira enjoyed monopoly status for two decades as AbbVie leveraged the court system to extend their patent protection and make deals with competitors to keep competing products off the shelves

The lawsuit brought by AbbVie targets PBMs and little known companies that exploit alternative funding arrangements for financial gain.

AbbVie, like many manufacturers offers financial aid for uninsured and underinsured patients.

Payer Matrix is one of those entities. We’ve seen contracts from PM that charge 27% of the savings for their assistance leveraging these financial aid programs.

Those savings fees rarely take into account the after rebate drug cost.

Thus, an employer can end up paying PM $22k for getting one patient their Humira for free through AbbVie’s assistance program.

PM isn’t alone in this game. Others like SHARx, ScriptSourcing, and even PBMs have gotten in the game. ScriptSourcing used to charge a 50% savings fee - I have the receipts.

Now AbbVie is crying fowl. Alleging racketeering and naming EmpiRx, Capital Rx, and Magellan PBMs as co-conspirators milking these programs and taking away funds from those in need.

These programs are opportunistic no doubt but it’s hard to sympathize with AbbVie who’s played the system better than anyone who’s come before. Remember: one drug, $200 Billion.

Now it’s off patent. Biosimilars are easily available for $800/month or less.

But Abbvie just moved the puck. Their focus is now on maximizing revenue on Skirizi and Rinvoq which come with even higher price tags.

It’s hard to argue that anyone can afford an $80k a year drug (or even $50k post rebate) when median household income is in the $50k range

So who should pay? Who can pay?

“It is amazing that people who think we cannot afford to pay for doctors, hospitals, and medication somehow think that we can afford to pay for doctors, hospitals, medication, and a government bureaucracy to administer it.”

-Dr. Thomas Sowell

Simpara Hosts 2nd Annual HEALTH x STL event at CITYPARK

On June 5, 2024 Simpara will host our 2nd annual HEALTH x STL heatlhcare innovation summit. The event is geared towards mid-sized employers in the region that are struggling to contain escalating healthcare costs.

HEALTH x STL is not just an event. It’s a movement where the brightest minds in business and health converge to share groundbreaking solutions for transforming health insurance and care.

Hear from the most innovative CEOs and Business Leaders who have eliminated deductibles, cut health spending in half, and restored meaningful wage growth to their number one asset.

Healthcare is already fixed. Join us to replicate the fixes and help transform our region.

LEARN MORE ABOUT OUR EVENT HERE: HEALTHXSTL.COM

Broker Compensation - Rx Kick Backs

Broker Compensation is a hot topic these days. With the passing of the CAA, brokers are required to disclose all direct and indirect forms of compensation they receive in exchange for brokering benefit plans for plan sponsors.

Unfortunately, there are myriad indirect forms of compensation that benefit brokers receive - hence our commitment to a fee-only approach. But the recent Johnson & Johnson lawsuit highlights how PBMs can influence broker recommendations and possibly result in conflicted interests. Here is an excerpt provided by our friends at True Scripts:

J&J Fiduciary Lawsuit

Prudence and Conflicts of Interest

While the J&J employee-participant's lawsuit does not specifically allege non-compliance with this new compensation disclosure requirement, the specter of non-compliance is implied. And such implication is tied back into the fiduciary duty to act prudently.

More specifically, the complaint devotes eight paragraphs asserting that plan fiduciaries must act prudently when hiring brokers and consultants to, for example, assist the plan in selecting and negotiating contract terms with a PBM. These paragraphs go on to explain that in many cases, brokers and consultants have a conflict of interest when recommending a particular PBM due to indirect compensation and

"kick-backs" (as the complaint puts it) paid to the brokers/consultants by the PBM.

Based on these points, the complaint asserts that plan fiduciaries must ensure that any broker/consultant they hire to help them select and negotiate with a PBM does not have a conflict of interest that would prevent the broker/consultant from offering objective advice. The exclamation point to these assertions is that a plan fiduciary's failure to obtain the required disclosures from a broker/consultant makes the contract with the broker/consultant a prohibited transaction under ERISA.

Lifetime Fitness launches Clinic Model

As reported in Fitt Insider…

Life Time is stretching its limits.

The latest: The fitness brand’s new medical concept, called MIORA, will offer comprehensive health testing and personalized wellness plans.

• For $299, patients receive a detailed blood panel, health report, and consultation.

• A $199 monthly membership includes access to services like peptides, hormone replacement therapy, IV drip, cryotherapy, sauna, red light therapy, and more.

• Personalized treatment plans will span lifestyle and medical interventions, plus GLP-1s.

The pilot location opens November 27 in its downtown Minneapolis club after soft launching this month.

Why it matters: With Ozempic and Wegovy here to stay, the fitness industry is being forced to adapt. MIORA comes on the heels of Life Time’s plans to offer weight loss prescriptions for members, an effort to encourage GLP-1 users to pair the drugs with long-term lifestyle changes.

Capitalizing even further, Life Time’s clinical offshoot adds holistic medical treatments to the equation — providing care and diagnostics beyond the capacity of gym trainers.

Zooming out: Outmaneuvering traditional healthcare, prevention-focused wellness centers, clinics, and spas are ramping up.

Companies like Restore Hyper Wellness and Pause Studio put recovery first, while Modern Age, Fountain Life, and Serotonin Centers emphasize longevity and anti-aging services.

Punchline: Formerly distinct industries, fitness and wellness have become a package deal. As more people embrace holistic health, expect the overlap of medical, lifestyle, and aesthetic interventions to continue.